A 51-year-old man was referred for progressive dyspnea and dry cough. He had received a diagnosis of emphysema 10 years previously, causing him to stop smoking. Dyspnea worsened, resulting in bronchodilator treatment 4 years previously; lung function had not been assessed. At the time of referral, the patient’s symptoms were ascribed to worsening emphysema by his primary physician. He had no constitutional complaints, skin or mucosal changes, arthritic symptoms, muscle weakness, or chest pain. His medical history was otherwise only significant for intermittent atrial fibrillation, for which he received therapy with digoxin. His occupational history was that he had worked in a factory making aluminum alloy automobile wheels beginning 9 years previously, but he had quit 3 years prior due to increasing dyspnea. However, due to financial hardship he had returned to this same job over the preceding 5 months, coincident with the worsening dyspnea. There were no other provocative exposures.